CurrentPremera BluecrossPolicy N/A

Modifier 54, 55, 56 — Surgical Care Only / Postoperative Management Only / Preoperative Management Only

Defines when Premera recognizes CPT services billed with modifiers 54, 55, or 56 to indicate partial performance of a global surgical package and how those services will be reimbursed; applies to professional claims and specified Premera/LifeWise lines of business.

Policy Summary

PayerPremera Bluecross

PolicyModifiers 54, 55, 56 — Surgical Care Only / Postoperative Management Only / Preoperative Management Only

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionAppend modifier 54, 55, or 56 and document the specific portion of the global service provided when only part of a global surgical package is performed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

70%modifier 54 reimbursement

20%modifier 55 reimbursement

10%modifier 56 reimbursement

CMS-1500/837Papplies to

Coverage Criteria for Split Global Surgical Services

Coverage rules for split global surgical services

Covered when ALL of the following are met:

Applies to CPT services with global periods of 10 or 90 days as identified in the CMS National Physician Fee Schedule.

The service is billed with modifier 54, 55, or 56 to indicate that one physician or other qualified healthcare professional performed only part of the global surgical package and relinquished the other portion(s) to another physician or other qualified healthcare professional belonging to a different practice.

Billing must accurately reflect the portion of the global services the billing physician or other qualified healthcare professional performed; documentation in the patient medical record must detail the specific services rendered for each portion of the global service.

Reimbursement will be adjusted by modifier: Modifier 54 reimbursed at 70% of the provider's applicable Fee Schedule allowed amount; Modifier 55 reimbursed at 20% of the provider's applicable Fee Schedule allowed amount; Modifier 56 reimbursed at 10% of the provider's applicable Fee Schedule allowed amount.

Policy Summary

PayerPremera Bluecross

PolicyModifiers 54, 55, 56 — Surgical Care Only / Postoperative Management Only / Preoperative Management Only

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionAppend modifier 54, 55, or 56 and document the specific portion of the global service provided when only part of a global surgical package is performed.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Billing, Documentation, and Enforcement

Denial Risk

Enforcement

The Plan may impose auditing, monitoring, corrective actions, contractual penalties, or termination for violations of this policy. Disciplinary actions will be appropriate to the seriousness of the violation and are determined at the Plan's sole discretion. Violations by any party that has a written arrangement with the Plan may result in increased auditing and monitoring, performance guarantee contractual penalties, corrective action (up to and including termination of the contract or employment), or other enforcement remedies.

Violations may trigger increased auditing and monitoring.
Performance guarantee contractual penalties may be applied.
Corrective actions may include termination of contract or employment depending on severity.

Documentation Required

Exceptions and Provider Documentation Responsibilities

Exceptions to this policy may be granted only when specified in a provider or employer group contract with the Plan. Providers are responsible for ensuring billings accurately reflect the portion of the global surgical package they performed and for maintaining documentation in the patient medical record detailing the specific services rendered. Documentation should support use of modifiers 54, 55, and 56 and be available for review during audits. Billing discrepancies should be resolved between the providers involved in patient care.

Exceptions only when explicitly allowed by a provider or employer group contract.
Providers must document services rendered for each portion of the global surgical package.
Documentation must support modifier 54/55/56 use and be available for audit.

Modifier Definitions

Modifier 54 — surgical care only

DefinitionModifier 54 indicates the physician or other qualified healthcare professional performed surgical care only and relinquished pre‑ or postoperative care to another physician or qualified healthcare professional belonging to a different practice.

Applies toCPT services identified in the CMS National Physician Fee Schedule with 10‑ or 90‑day global periods.

Documentation requirementPatient medical record must detail the specific portion of the global service rendered by the provider billing with modifier 54.

ExclusionDoes not apply to assistant surgeon services.

Modifier 55 — postoperative management only

DefinitionModifier 55 indicates the physician or other qualified healthcare professional performed postoperative management only while another provider performed the surgical care, each belonging to a different practice.

ReimbursementReimbursed at 20% of the provider's applicable Fee Schedule allowed amount.

Documentation requirementPatient medical record must detail the postoperative services rendered for billing with modifier 55.

Modifier 56 — preoperative management only

DefinitionModifier 56 indicates the physician or other qualified healthcare professional performed preoperative management only while another provider performed the surgical care, each belonging to a different practice.

ReimbursementReimbursed at 10% of the provider's applicable Fee Schedule allowed amount.

Documentation requirementPatient medical record must detail the preoperative services rendered for billing with modifier 56.

OpenPayer

Modifier 54, 55, 56 — Surgical Care Only / Postoperative Management Only / Preoperative Management Only

Coverage Criteria for Split Global Surgical Services

Applicable Modifiers and Reimbursement

Billing, Documentation, and Enforcement

Modifier Definitions

Modifier 54	Surgical care only
Modifier 55	Postoperative management only
Modifier 56	Preoperative management only